Analysis of Intraoperative Neurological Complications in High-Risk Spinal Surgery with the Use of Motor Evoked Potential Monitoring

Jin-Hyok Kim; Dong-Ju Lim; Sung-Soo Kim; Se-Il Suk; Min-Kyu Kim

doi:10.4184/jkss.2011.18.3.153

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Kim, Lim, Kim, Suk, and Kim: Analysis of Intraoperative Neurological Complications in High-Risk Spinal Surgery with the Use of Motor Evoked Potential Monitoring

Original Article

Journal of Korean Spine Surg 2011;18(3):153-162.

Published online: 21 September 2011

DOI: https://doi.org/10.4184/jkss.2011.18.3.153

Analysis of Intraoperative Neurological Complications in High-Risk Spinal Surgery with the Use of Motor Evoked Potential Monitoring

Jin-Hyok Kim, M.D., Dong-Ju Lim, M.D., Sung-Soo Kim, M.D., Se-Il Suk, M.D., Min-Kyu Kim, M.D.

Seoul Spine Institute, Sanggye Paik Hospital, College of Medicine, Inje University

Corresponding author: Dong-Ju Lim, M.D. Seoul Spine Institute, Sanggye Paik Hospital, College of Medicine, Inje University, 761-1 Sanggye Dong, Nowon-ku, Seoul, 139-707, Korea TEL: 82-2-950-1290, FAX: 82-2-950-6342 E-mail: scd25@paik.ac.kr

Received 16 June 2011 Revised 16 September 2011 Accepted 16 September 2011

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Study Design

This is retrospective study.

Objectives

To evaluate the risk of operative techniques using Motor Evoked Potential (MEP) in high-risk spinal surgery.

Summary of Literature Review

There are few studies regarding the evaluation of operative techniques by MEP.

Materials and Methods

We studied 33 cases that had MEP during surgery from July 2007 to March 2009. Diagnoses included post-traumatic kyphosis (PTK) in eight cases, congenital deformity in eight cases, degenerative lumbar deformity in eight cases, ankylosing spondylitis (AS) in three cases, spinal tumor in three cases, adjacent segmental disease in two cases, and post-surgical kyphosis in one case. Posterior vertebral column resection (PVCR) and pedicle subtraction osteotomy (PSO) were performed in 27 cases (81.8%) and, in the others, posterior decompression with discectomy was performed. We analyzed the risk of operative techniques and evaluated the MEP.

Results

MEP showed abnormal signal change in five cases (PVCR: one case, compression and distraction: four cases). The AS case did not demonstrate neurological change after surgery. Though the PTK on T12 operated by PVCR case did not show an abnormal MEP result, neurological change was observed postoperatively. The sensitivity, specificity, percent of false negatives, and percent of false positives of MEP were 80.0%, 96.4%, 20.0%, and 3.6%, respectively.

Conclusions

MEP monitoring is a useful method to detect neurological injury during high-risk spinal surgery with satisfactory specificity. For low sensitivity and a high false negative rate, increased monitoring of cases and continuous followup is needed. In conclusion, compression and distraction and PVCR are high-risk techniques in kyphotic deformity correction.

Keywords: High-risk spinal surgery, Motor Evoked Potential (MEP), Operative technique, Neurological complication

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Figures and Tables%

Fig. 1.

(A) Female 46-years, post traumatic kyphosis (B) after decompression & PVCR (C) channel 4 showed normal MEP response before compression & distraction (D) channel 4 showed that amplitude was decreased above 80% at left lower limb immediately after compression & distraction.

Fig. 2.

(A) Male 57-years, ankylosing spondylitis with kyphosis (B) after PVCR and compression (C) channel 8 showed normal MEP response before PVCR (D) channel 8 showed that amplitude was decreased above 80% at right lower limb immediately after PVCR and compression.

Fig. 3.

(A) Female 66-years, post traumatic kyphosis (B) after decompression and PVCR (C) channel 8 showed normal MEP response before decompression and PVCR (D) channel 8 showed normal MEP response after decompression and PVCR but she woke up with both lower limb motor grade 3.

Table 1.

Details of the Patients with MEP monitoring during Spinal Surgery.

Case	Sex	Age	Diagnosis	Fusion level	Procedure level	Prior Surgery	MEP change	Neurological deficit
1	Male	59	PTK	T10-L3	L1 PVCR	N	N	N
2	Female	66	ASD	T10-L4(L2-4)	Decompression	Y	N	N
3	Female	74	LDK	T10-S1	L3 PSO	N	Y	Y
4	Male	55	CK	T11-L5	L2 PVCR	N	N	N
5	Female	67	PTK	T8-S1	L3 PSO	N	Y	Y
6	Female	39	CKS	T3-L4	T9 PSO	N	N	N
7	Female	74	PTK	T9-L2	T12 PVCR	N	N	N
8	Female	65	LDK	L1-S1	L4 PSO	N	N	N
9	Male	12	CKS	T9-L2	T12 PVCR	N	N	N
10	Male	16	CKS	T7-L4	T11,12 PVCR	N	N	N
11	Female	59	LDK	T11-S1	L3 PSO	N	N	N
12	Male	57	AS	T10-S1	L3 PVCR	N	Y	N
13	Female	61	DLS/LDK	T10-S1	L3 PSO	N	N	N
14	Female	67	LDK	T11-S1	L3 PVCR	N	N	N
15	Female	57	ASD	T11-S1(T11-L5)	Decompression & discectomy	Y	N	N
16	Female	46	PTK	T6-L2	T10 PVCR	N	Y	Y
17	Female	10	CS	T3-L4	T8 PSO	N	N	N
18	Female	64	ASD	T10-S1(L1-L5)	Decompression & discectomy	Y	N	N
19	Female	58	Tumor (L1 Schwannoma)	T11-L3	Decompression	N	N	N
20	Male	60	Postop Kyphosis	T10-S1(T12-L4 Laminectomy)	L3 PSO	Y	N	N
21	Male	14	CS	T3-L1	T7 PSO	N	N	N
22	Female	66	PTK	T8-L3	T12 PVCR	N	N	Y
23	Female	16	CKS	T1-T10	T3 PVCR	N	N	N
24	Female	73	PTK	T10-L2	T12 PVCR	N	N	N
25	Female	54	CS	T11-S1	L3 PVCR	N	N	N
26	Female	51	PTK	T11-S1	L1 PVCR	N	N	N
27	Female	31	Tumor (L2 RCC metastasis)	T12-L4	L2 PVCR	N	N	N
28	Female	59	DLS	T8-L5(L4-L5 Laminectomy)	Decompression	Y	Y	Y
29	Female	68	PTK	T10-S1	L1 PVCR	N	N	N
30	Female	63	DLS	L1-S1	L4 PSO	N	N	N
31	Female	62	AS	T9-L3	T12 PSO	N	N	N
32	Male	65	AS/ASD	T7-L4(T9-L2)	L2 PSO	Y	N	N
33	Male	40	Tumor (L2 Schwannoma)	L1-L3	Decompression	N	N	N

PTK = post traumatic kyphosis; SS = spinal stenosis; ASD = adjacent segmental disease; LDK = Lumbar degerative kyphosis; CK = congenital kyphosis; CKS = congenital kyphoscoliosis; AS = ankylosing spondylitis; DLS = degenerative lumbar scoliosis; CS = congenital scoliosis; RCC = renal cell carcinoma.

Table 2.

Comparison clinical outcome to MEP monitoring outcome.

	Postoperative neurological deficit
	Positive	Negative
MEP (+)	4	1	Positive predictive value :80.0 %
MEP (-)	1	27	Negative predictive value : 96.4%
	Sensitivity : 80.0%	Specificity : 96.4%
	False positive proportion : 3.6%
	False negative proportion : 20.0%		%

Table 3.

Risk factors of neurological injury during high-risk spinal surgery.

Abnormal anatomy
Incorrect pedicle screw insertion
Kyphotic deformity correction
Direct vascular injury
Direct nerve injury
Indirect ischemia due to decrease of vascular diameter

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